GROUP MEDICAL VISITS FOR THE TREAMENT OF ASIAN PACIFIC ISLANDERS WITH CHRONIC DISEASES

1. GROUP MEDICAL VISITS FOR THE TREAMENT OF ASIAN PACIFIC ISLANDERS WITH CHRONIC DISEASES Ritabelle Fernandes, MD, MPH Maricel Abad, RN Patsy Uehara, RD Riano Nazareth, AS Ann Jimenez McMillan, MPH

2. Objectives • Explain the different models of Group Visits • Understand the delivery of care using multidisciplinary approach within a group visit setting • Improve provide productivity using group visits

3. Why Group Visits? • Increases patient satisfaction • Support and empowerment from peers • Improves access to care • Education about disease • Improves outcomes • Increases productivity Trento et al. Lifestyle intervention by group care prevents deterioration of type 2 diabetes: a 4 year Randomized control trial. Diabetologia 2002;45:1231-1239

4. Different Models for Group Visits • DIGMA – Drop In Group Medical Appointment • CCHC – Cooperative Health Care Clinics • Continuing Care Clinic • Cluster Visits for Diabetes Care • CDSMP - Chronic Disease Self Management Program • Support Groups

5. Studies - Diabetes Group Visits • Sadur et al. study of Diabetes Cooperative Care Clinics providing cluster visits multidisciplinary care model for patients with diabetes in a HMO setting has shown improvement in HbA1Cand increased confidence in self management behaviors • Wagner et al. conducted a system wide randomized control trial of chronic care clinics for diabetes in a HMO setting and found increased preventative procedures among attendees • Clancy et al. found group visits excellent for promoting concordance with ADA guidelines in uninsured and underserved populations improving the quality of care

6. Kokua Kalihi Valley & Kalihi-Palama Health Center

7. Kokua Kalihi Valley Gulick Elder Center (monthly) - Memory clinic Kuhio Park Terrace (bi monthly) - Diabetes Main Clinic - Diabetes (monthly) - Kidney Disease (bi monthly) Kalihi Palama Health Center - Asthma/COPD (monthly) - Diabetes (weekly cycles) Chronic Disease Group Visits

8. Mail Invitations -REMINDER- For: Come and join us for our DIABETES CLASS It is held at the Conference Room 2nd floor of KKV Health Center every 1st Wednesday of the month We will learn more on how to control and manage our diabetes. We will have FREE healthy meals cooked by our great nutritionists. We will also have some PRIZES!! HOPE TO SEE YOU THERE!!

9. Reminder calls

10. Transportation

11. Waiting Room

12. Lunch Room/Reading Room

13. Group Visit Format 8.30 - 8.45 Check In 8.45 - 9.15 Vital signs and history taking 9.15 - 9.30 Participants introduction/sharing 9.30 - 10.30 Educational presentation 10.30 - 11.00 Break One on one with physician 11.00 - 11.30 Lunch with nutritional counseling 11.45 - 12.00 End Follow up appointments given Wellington M. Stanford health partners: Rationale and early experience in Establishing physician group visits and chronic disease self –management workshops. J Ambulatory Care Manage 2000; 24(3):10-16

14. Sign In

15. Vital Signs

16. Taking History

17. Introductions

18. Topics

19. Facilitative Teaching Style

20. Presentation - Glucometer Teaching

21. Incentives

22. Break - Medication Refill • Samples • Patient Assistance • 340 B • Prescriptions

23. Immunizations

24. Meet with Doctor

25. Healthy Lunch

26. How to get started? • COLLABORATION • Partner with existing education/support groups • Frequency • Reserve Room • Delegate duties • Team - Standing Orders • SUSTAINABILITY

27. Patient Selection, Recruitment, Retention • Group visits by Language/ethnicity • Limited to individual provider’s panel • Open access to all providers • Community Health Workers • Work close proximity to health maintenance group, day care • Food, Incentives are key • Challenges – Language barriers, dementia or psychiatric issues, time constraints

28. Staffing • Medical Students, Residents, Fellows • Public Health Nurses • Guest speakers • Interpreters • Medical Assistants • Nutritionist • Behavioral Health • Eligibility • Tobacco Cessation Specialist • Pharmacy

29. Advantages of Provider Presence CARE COMPONENT IN ADDITION TO EDUCATION COMPONENT • Medications can be ordered/refilled • Symptom management • Phlebotomy, Immunizations, tests can be ordered • Referrals made to specialists • Time for Q & A

30. KOKUA KALIHI VALLEY COMPREHENSIVE FAMILY SERVICES FEE TICKET LABEL ARRIVAL TIME:____________ INSURANCE:_______________ EFF DATE WITH KKV:______ REFERRING PCP:_________________ INTAKE INITIAL:___________ UPIN #:__________________________ CHART REVIEW:___________

31. Increase Revenue and Productivity • Physician – 99212 or 99213 • Certified Diabetes Educator (ADA certified site) – G0108, G0109 • Smoking Cessation – G 0375 or 99406 • Reimbursed for In-House laboratory eg. Point of Care Testing, Spirometry • UDS numbers – interpreter and other enabling services

32. Preliminary Data 2006 – KKV Diabetes Group A, B, Cs

33. Preliminary Data 2007 – KKV Diabetes Group A, B, Cs

34. 2007 Self Efficacy Data Stanford diabetes self efficacy scale

35. 2007 Diabetes Quality of Life

36. Satisfaction Survey 2008 (N=19) * Based on a 1-5 Likert scale 1 = strongly disagree to 5 = strongly agree

37. Comments • I come every time we have a diabetes class because I learned everything regarding diabetes and trying to apply at home • I thankful this program. So I know what kinds of food I eat. It good to my diabetic • I really like this group because I learn a lot about my diabetic this group is good for every patient has diabetic

38. Public Health Nurse’s Role Diabetes Group Visits

39. HEALTH EDUCATION CHECK BLOOD GLUCOSE MEDICATION and INSULIN HEALTHY EATING • GENERAL HEALTH INFORMATION MANAGING DIABETES

40. HEALTH EDUCATION FOOT CARE HYPERLYCEMIA/ HYPOGLYCEMIA PREVENTING COMPLICATIONS

41. HEALTH EDUCATION EASY TO UNDERSTAND BASED ON GROUPS NEED UTILIZE DIFFERENT METHODS OF TEACHING ENCOURAGE PARTICIPATION

42. Creative, Interactive and Fun

43. GROUP FACILITATOR Facilitative Leadership Style Encouraging Discussions Learning through each other’s experiences

44. Goal Setting

45. COORDINATE ACTIVITIES COLLABORATING WITH OTHERS HAVING GUEST SPEAKERS SET CURRICULUM BEING FLEXIBLE

46. ENCOURAGING STAFF DEVELOPMENT ALLOWING STAFF TO PARTICIPATE IN GROUP SESSIONS MOTIVATING STAFF MEMBERS TRAINING THROUGH MODELING OPPORTUNITY FOR STAFF TO INTERACT WITH CLIENTS

47. INCORPORATING CULTURE • PARTICIPANTS ARE OF DIFFERENT CULTURES • SHARING CULTURAL BACKGROUND- • FOOD • BELIEFS • OPPORTUNITIES FOR FAMILIAR HEALTHY CULTURAL ACTIVITIES • ALLOWING PARTICIPANTS TO SPEAK IN THEIR LANGUAGE • USE OF INTERPRETERS WHEN NEEDED

48. Cultural Adaptations - Music • Dance • Exercise, stretching

49. Exercise

50. HOOULU ‘AINA • KKV ROOTS PROJECT • PROMOTING HEALTH THROUGH (CINRTR: • CONNECTING TO THE LAND and the FOOD GROWN • CONNECTING WITH EACH OTHER and LEARNING ABOUT EACH OTHERS CULTURE • SENSE OF COMMUNITY • APPRECIATING HEALTHY CULTURAL FOODS